Richard M. Fairbanks School of Public Health Theses and Dissertations
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Item Studies Examining Maternal Vaccination Decisions and Influenza Burden in U.S. Infants Ages 0-5 Months(2025-11) Albertin, Christina Susanne; Dixon, Brian; Duszynski, Thomas; Zimet, Greg; Turman, Jack E.Introduction Pregnant women and young infants are particularly vulnerable to respiratory viral infections, but infants aged 0-5 months cannot receive COVID-19 and influenza vaccines, making maternal vaccination a key prevention strategy. We examined changes in rates of maternal COVID-19 and influenza vaccination, influenza-associated hospitalization burden and characteristics of influenza positive infants aged 0-5 months by acute care setting. Methods Data from two health systems and a surveillance network were analyzed. Study 1 examined COVID-19 and influenza vaccination patterns between two temporal cohorts of pregnant women (2021-2023, n=5,949). Study 2 compared characteristics of influenza-positive and influenza-negative hospitalized infants aged 0-5 months and calculated an influenza hospitalization rate for this age group from 2016-2020 (n=2,605). Study 3 compared infants with laboratory-confirmed influenza discharged from the emergency department versus hospitalized (n=210). Results In Study 1, COVID-19 vaccinations fell substantially between the two cohorts (62% to 26%), while influenza vaccination showed a lesser decline (52% vs 48%). Those receiving neither vaccine increased (26% to 44%). Study 2 found influenza-positive infants had less severe illness than influenza negative infants, 79% of whom tested positive for other viral pathogens. The calculated influenza hospitalization rate was 129.5 per 100,000 infants. Study 3 identified younger age and underlying condition as associated with hospitalization (aOR 4.37, 95% CI 2.11-9.06, aOR 6.29, 95% CI 2.34-16.86). Public insurance and higher maternal education had lower odds (aOR 0.12, 95% CI 0.04-0.34), aOR 0.36, 95% CI 0.14-0.91). Conclusion Our calculated influenza hospitalization rate (2016-2020) was significantly lower than historical estimates from the 2000s, coinciding temporally with increased national maternal influenza vaccination coverage. Our analysis of influenza among infants aged 0-5 months demonstrated that influenza comprised a small proportion of acute respiratory illness hospitalizations. Maternal vaccination patterns revealed declines in uptake of both vaccines between 2021-2023, with COVID-19 vaccination showing the steepest decrease. Considering recent national declines in maternal influenza vaccination, our findings underscore the importance of developing targeted interventions to improve maternal vaccination coverage and sustain reduced influenza hospitalization burden in this age group.Item Medicaid Continuous Eligibility and its Associations with Administrative Costs, Unmet Needs, and Health Service Utilization(2025-10) Tran, Yvette Ho; Blackburn, Justin; Holmes, Ann M.; Vest, Joshua R.; McFarlane, Timothy D.Medicaid acts as a vital safety net in the United States—providing health insurance for households with limited income, seniors needing long-term care services, and persons with disabilities. However, income fluctuations and unsuccessful Medicaid renewals result in transient lapses in coverage for some enrollees, otherwise known as churn. Prior studies have estimated that around eight percent of enrollees experience churn within a year. Enrollees experiencing churn may be more likely to delay or forgo preventive care, potentially leading to adverse health outcomes and higher healthcare costs downstream. Policies such as implementing ex parte renewals or reducing the number of eligibility checks conducted each year have helped to reduce, but not eliminate, churn. In March of 2020, the United States Congress passed the Families First Coronavirus Response Act, which introduced maintenance of effort (MOE) requirements in exchange for enhanced federal funding to states. To comply with MOE requirements, states ensured enrollees had continuous eligibility throughout the public health emergency period, which spanned March 2020 through March 2023, regardless of changes in financial circumstances. This policy temporarily eliminated almost all churn and contributed to record high Medicaid enrollment, but its consequences for administrative cost, unmet healthcare needs, and service utilization are unclear. The purpose of this dissertation is to assess the relationship between continuous eligibility policy and 1) administrative costs; 2) unmet medical, dental, and prescription medication needs; and 3) health service utilization. This dissertation includes three studies: 1) a pre-post analysis of state-year panel data that assesses trends in overall, per-enrollee and per capita administrative spending; 2) a difference-in-difference with inverse probability weights analysis that examines the relationship between churn and unmet medical, dental, and prescription medicine needs; and 3) a comparative interrupted time series study that compares changes in well-child, preventive dental, office-based, emergency department, and hospital encounters by history of churn. With Medicaid consuming about eight percent of federal and 30 percent of state budgets, respectively, policymakers have and will consider Medicaid financing reform, benefits redesign, and innovations in eligibility and renewal policies. Evidence from this dissertation will help inform policymakers about the tradeoffs of various decisions and priorities.Item Barriers to Trust in the Utilization of Health-Related Social Needs Data from the Electronic Health Record(2025-08) Allen, Katie Sue; Vest, Joshua R.; Blackburn, Justin; Dixon, Brian; Yeager, ValerieAddressing health-related social needs (HRSN)—such as food insecurity, housing instability, transportation barriers, and financial strain—is increasingly recognized as essential to achieving equitable health outcomes. These factors play a critical role in shaping patients’ health risks, care access, and health outcomes. Consequently, understanding and addressing HRSN is vital to both clinical decision-making and population health management. The electronic health record (EHR) holds promise as a tool for the systematic collection and use of HRSN data. However, current practices are marked by inconsistencies and limited adoption of structured coding systems. Highquality, standardized data are critical for the meaningful application of HRSN information, yet multiple barriers hinder collection. These challenges are not solely technical. Patients may be reluctant to disclose sensitive social information, and clinicians may feel discomfort or uncertainty about asking, recording, or acting on such data. These attitudinal and structural obstacles introduce the potential for bias in EHRderived data, which may compromise the fairness and effectiveness of downstream applications. If unaddressed, these limitations may undermine trust in the utility and accuracy of EHR-based social factors data. This dissertation investigates the structural and attitudinal factors that influence trust in EHR-derived HRSN data, with a focus on data quality, documentation practices, and clinician perspectives. First, it evaluates the robustness of EHR-based HRSN data by comparing prevalence estimates derived from structured fields with external community benchmarks. Discrepancies highlight areas where under-documentation or misrepresentation may occur. Second, the study examines demographic and system-level characteristics associated with whether patients’ social needs are captured in the EHR, identifying patterns that may reflect disparities in documentation. Third, semi-structured interviews with clinicians provide qualitative insight into their experiences documenting HRSN, their trust in the data’s accuracy, and their perceptions of its role in clinical care. Together, these mixed-methods investigations offer a comprehensive understanding of the barriers and facilitators to trustworthy and equitable use of HRSN data within EHRs. Findings will inform future strategies to strengthen data quality, enhance clinician engagement, and ensure that EHR-derived social factors data can be reliably leveraged to support health equity and improved patient outcomes.Item Exploring Awareness of Implicit Bias Within New Zealand's Chronic Pain Management Healthcare Workforce: Is Current Regulation Serving Them Best?(2025-06) Bowering, Lara Jane; Archer, Sarah; Yeager, Valerie A.; Chadwick, MartinObjective: To explore the knowledge and beliefs about implicit bias in chronic pain management healthcare practitioners in New Zealand and analyse the current Regulatory Authority competence documents and guidelines, regarding the topic of implicit bias. Additionally, provide recommendations for Regulatory Authorities regarding implicit bias messaging, training and competence framework implementation. Setting: Interviews were carried out with members of both public and private Chronic Pain Management Services across New Zealand from February 2025 to May 2025. Relevant Regulatory Authority documents were analysed during February 2025 to March 2025. Study Design: The research study was an exploratory mixed-methods approach. The qualitative portion involved semi-structured healthcare practitioner interviews. The Regulatory Authority documents were analysed independently for words and narrative. Data was then combined and analysed to obtain detailed insights for making recommendations. Data collection: Microsoft teams was used to audio record and transcribe interviews with 15 healthcare practitioners. Interviews were coded using NVivo to identify themes. Regulatory Authority documents were accessed online and explored manually as well as word searched electronically. Principal Findings: Several themes emerged from participant interviews regarding sources of perceived knowledge, associated emotions and actions and the perceived effects of implicit bias. A varied understanding of the concept exists within the cohort and few healthcare practitioners get their information about implicit bias from their Regulatory Authority: An impression of lack of agency regarding change was observed in all interviews. Even though competence and code of ethics documents are extensive, they lack definition, measurement or suggested training options for their members regarding implicit bias. Discussion: This study is the first in New Zealand to qualitatively explore the beliefs and knowledge of any healthcare workforce cohort about implicit bias. Current levels of knowledge are being impacted by a lack of guidance and definition from Regulatory Authorities as well as overall support and access to relevant evidence-based training options. Conclusion: Simple changes within Regulatory Authority documentation, as well as cross-authority collaboration, could positively impact levels of implicit bias knowledge alongside training uptake. These easily implemented changes are needed to promote movement towards the healthcare service goal of patient-centred care.Item Exploring the Intersection of Substance Use, Mental Health, and Mortality Among the U.S. Youth: A Comprehensive Analysis of Trends, Associations and Interventions(2025-07) Jain, Nitika; Han, Jiali; Nan, Hongmei; Monahan, Patrick O.; Harle, ChrisMy PhD journey has been long and eventful, filled with various personal milestones and challenges. I experienced the joy of welcoming my daughter into the world, changing two jobs, and relocating across two homes and states while also enduring the deep sorrow of losing my beloved grandfather. Despite moments of self-doubt and instances where I almost felt like giving up, this journey has strengthened my wisdom and resilience. Through it all, one constant remained, my passion for driving meaningful change in the field of mental health and substance use, supported by the unwavering encouragement of my community, which kept me moving forward, one small step at a time. As they say, great ideas are not the work of one, but the product of a well-knit supportive community. So, with that in mind, I dedicate my dissertation to the following: 1. My loving husband and beautiful daughter, who have been my unshakable pillars of strength and support throughout the journey. 2. My parents, in-laws, and extended family in India, who instilled in me values of integrity, honesty, and humility, virtues that are reflected throughout my dissertation. 3. My late grandfather, whose constant encouragement to stay curious, fueled my passion. He often asked me “When will you finish your PhD” and “I can’t wait to read your dissertation”. So, Daddy, this one is for you! 4. My incredible friends whose words of motivation kept me going whenever I thought of giving up, especially Dr. Rizwana Biviji, my dear friend and IU PhD program alumna, who has been my moral support and inspiration throughout. 5. My mentors and teachers in India, Mauritius, and the U.S., who instilled in me the importance of questioning, learning, and following the path of science and facts. 6. Last but not least, all those young promising individuals who tragically lost their lives to the menace of substance use and mental illness. Their struggles and the lessons learned from their short but impactful lives inspire us to strive for positive change in communities.Item Improving Supply Chain Systems for the Efficient Monitoring of Medical Countermeasures During Public Health Emergencies in the Federal Capital Territory, Nigeria: Recommendations for Systems and Policy Improvement(2025-07) Aminu-Alhaji, Asmau; Babich, Suzanne Marie; Joseph, Gbenga Solomon; Duszynski, Thomas J.During the COVID-19 pandemic, the Nigeria Center for Disease Control and Prevention (NCDC) encountered significant challenges in maintaining visibility over medical countermeasures (MCM) deployed to sub-national levels. A nonexperimental, descriptive research design using semi-structured key informant interviews (KII) was employed to gather qualitative data on what factors contributed to poor visibility of deployed MCMs in the Federal Capital Territory (FCT), Nigeria. This research focused on the FCT but reflected a broader nationwide challenge. Key informant interviews were conducted, and data analysed employing deductive and inductive coding to identify main themes. Secondary data were obtained from literature reviews. Findings showed NCDC's logistics and supply chain system was unprepared for the COVID-19 pandemic, underscoring the need for improved emergency preparedness and readiness. An MCM strategic plan existed but was not fully developed or operationalized at the onset of the pandemic. NCDC relied on the FCT’s Department of Public Health (DPH) for its supply chain management, despite the Department of Pharmaceutical Services (DPS) being responsible for FCT's established public health supply chain system. NCDC and the FCT had an insufficient workforce with limited experience in managing a large-scale outbreak response. The public health workforce was insufficient with noticeable gaps in training that impacted overall effective management. NCDC’s electronic logistics management information system at the time of the pandemic was not integrated with other existing reporting systems and did not support end-to-end transactions. Efforts to automate the system for end-to-end visibility were unsuccessful forcing NCDC to resort to manual operations. The absence of a national reporting tool and standardized guidelines further hindered effective tracking and reporting of MCMs. Unlike other government agencies, such as the National Primary Health Care Development Agency (NPHCDA), which maintained visibility and control over vaccine distribution through established networks and collaboration, NCDC did not leverage existing resources and structures. Strengthening coordination across agencies, clarifying roles, investing in workforce capacity, and implementing integrated digital systems should be prioritized within revised policy frameworks to ensure better preparedness and visibility in future public health emergencies.Item Obesity Severity Phenotypes, Relevant Biomarkers, and Cardiovascular Disease: The Cross-Cohort Collaboration (CCC)(2025-05) Dardari, Zeina; Zhang, Jianjun; Bakoyannis, Giorgos; Nan, Hongmei; Staten, Lisa; Blaha, MichaelThe global obesity pandemic is well documented and continues to pose a major public health threat. In 2022, the World Health Organization (WHO) classified more than 2.5 billion adults worldwide as overweight, including 890 million with obesity. In the U.S., projections indicate that by 2030, 1 in 2 adults will have obesity (BMI ≥30 kg/m²), and 1 in 4 will have severe obesity (BMI ≥35 kg/m²). Obesity is a well-established risk factor for numerous diseases, including type 2 diabetes mellitus, hypertension, obstructive sleep apnea, fatty liver disease, osteoarthritis, cancer, and cardiovascular disease (CVD), such as coronary heart disease (CHD), stroke, heart failure (HF), and atrial fibrillation (AF). Using the Cross Cohort Collaboration (CCC), a harmonized dataset of 24 U.S.-based prospective cohort studies, we examined the relationship between BMI and CVD outcomes across a broad BMI spectrum, with a focus on severe obesity (Class II: BMI 35.0–39.9 kg/m²; Class III: BMI ≥40.0 kg/m²). Our findings show that while obesity was associated with increased risk for all outcomes, stratifying obesity into sub-classes revealed that relative risk increases with obesity severity, even after accounting for traditional CVD risk factors. We also evaluated the long-term impact of central adiposity on multiple CVD subtypes, with particular attention to discordant adiposity groups (e.g., normal BMI with elevated central adiposity). Our findings underscore the need to identify and address central obesity, even among individuals with a normal BMI. These results support incorporating central adiposity measures as routine clinical assessments to improve cardiovascular risk stratification. Finally, we explored the relationship between obesity and subclinical markers of inflammation, thrombosis, and atherosclerosis to better understand underlying mechanisms. Our results demonstrated a positive, graded association between BMI and elevated levels of these markers, with the strongest associations observed in Class III obesity.Item Aligning Priorities Between Community Need for Lung Cancer Screening Programs and Hospital Effectiveness - A Policy Analysis(2025-05) Tackett, Scott Michael; Marstein, Egil; Babich, Suzanne; Culbertson, RichardObjective: Investigate structural factors impacting the prioritization and funding of public health preventive lung cancer screening programs in U.S. hospitals. Additionally, provide change leadership recommendations on policies to improve the implementation of evidence-based practices. Data sources and study setting: Data was gathered through a systematic literature review and primary qualitative research from health system or hospital organizational leadership across the U.S. Study design: The research employed a descriptive, non-experimental, convergent mixed-methods approach. Quantitative and qualitative data were collected and analyzed independently, then combined to obtain detailed insights from various perspectives across a diverse system for a situational analysis. Data Collection and Methods: A systematic literature review, combined with semi-structured interviews with Chief Medical Officers, Chief Financial Officers, and lung cancer program executives, was conducted across U.S. hospitals and health systems. Purposive sampling included thirteen dyad executive pairs and two executives from integrated delivery network lung cancer programs, representing various regions with a 'representative voice' of 6% of U.S. hospitals. Principal findings: The data synthesis identified 18 factors affecting lung cancer screening programs, categorized into five themes: differing missions, governance models, misaligned economics, competing goals, and broad agreements. These themes illustrate national discussions influencing the implementation of these types of preventive public health programs in hospitals and integrated delivery network organizations. Discussion: Despite efforts to implement evidence-based practices, outcomes and annual adherence rates remain low, showing room for improvement. This study is the first to provide empirical evidence that system-level factors in healthcare governance, processes, economics, and strategic decisions significantly influence the prioritization and investment in lung cancer screening programs and initiatives to implement an evidence-based practice. Summary & Conclusions: CMS should implement policies linking quality measurement with economic incentives in lung cancer care. These policies aim to prioritize investments supporting implementation practices. Their adoption requires political and agency leadership and represents a significant shift in approach. Aligning with these types of motivating economic incentive policies could impact the entire U.S. healthcare system.Item Establishing Policy Governance for Department of Defense Global Health Engagement Supporting United States Government Security, Defense, and Global Health Security Priorities: A Policy Analysis(2025-02) Cincotta, Jacqueline Viola-Ann; Babich, Suzanne; Marstein, Egil; Petzing, StephanieIntroduction. The United States (U.S.) Department of Defense (DoD) conducts DoD Global Health Engagement activities to support U.S. national, defense, and global health security priorities. The guiding policy for DoD Global Health Engagement is DoDI 2000.30 “Global Health Engagement Activities.” Problem Statement. The current DoDI 2000.30 “Global Health Engagement Activities” lacks an established governance framework and structure to oversee and ensure DoD Global Health Engagement activities enable U.S. national, defense, and global health security priorities. Methods. A complete policy analysis was conducted to devise policy alternatives for establishing DoD Global Health Engagement governance in DoD Global Health Engagement policy. Results. The policy analysis identified direct and indirect linkages DoD supports U.S. national, defense, and global health security priorities, as well as associated gaps in current DoD Global Health Engagement policy. Policy Alternatives & Plan-of-Action: A proposed DoD Global Health Engagement Governance Framework is introduced to recommend incorporating into DoD Global Health Engagement policy, as well as a plan-of-action utilizing social marketing to facilitate uptake of the proposed governance framework.Item Leadership Changes to Support Healthcare Providers with Long COVID Care(2025-04) Weideman, Angela Katherine; Czabanowska, Katarzyna; Bigatti, Silvia; Modji, KomiObjective: To explore how public health leaders and long COVID stakeholders from the Midwest United States can best support healthcare providers in providing long COVID care and how they can help ease the burdens of such care. Data sources and study setting: Qualitative interviews with 34 long COVID stakeholders from the Midwest region of the United States, from 15 different stakeholder groups, were collected from December 2024 to February 2025. Study Design: The research design was a qualitative study in which key informant interviews were conducted with stakeholders of long COVID using a semi-structured interview. Data collection: Semi-structured, one-on-one interviews were conducted virtually using Microsoft teams, and interviews were audio recorded and transcribed using Microsoft teams. Interviews were then coded using NVivo for inductive coding, used to identify and describe themes. Principal findings: The challenges identified related to diagnosis, access to care, provider concern, communication, and treatment. Stakeholders identified that they have impact and influence related to helping patients get to diagnosis and treatment more quickly, setting or supporting policies, making long COVID a priority in their organizations, making it easier for people to access long COVID care, and to support the people who are giving long COVID care. Numerous strategies were offered by stakeholders for supporting healthcare providers who are providing long COVID care. These include better characterization of the disease, increased treatment options, increased prevention efforts, advocacy, communication strategies, support for providers, collaboration with stakeholders, policy development, and learning from the success of advancement of care for other chronic conditions. Conclusion: Long COVID is a novel condition that requires change leadership support especially in the areas of diagnosis, access to care, communication, treatment, and provider knowledge and relations. It will take a multidisciplinary approach from a variety of stakeholders to create and implement a plan to support healthcare professionals who provide long COVID care. If these changes can be implemented and maintained, those who are suffering with long COVID symptoms can get to diagnosis and treatment more quickly and receive better quality care and treatment. This will have a positive impact on long COVID patients, their family members, employers, schools, medical professionals, health systems, governments, and the economy.